RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00664
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070901

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E4, Utilities Man, medically separated for “daytime hypersomnolence,” rated at 20%.  

CI CONTENTION:  The CI contended TBI, narcolepsy, cervical spine fusion, lower spine/back, left arm, right wrist, seizure activity, stomach and intestinal problems, lower extremities, obstructive sleep apnea and migraine headaches.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.   

RATING COMPARISON:  

SERVICE PEB - 20070713	VARD - 20080628	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Daytime Hypersomnolence	8045-8199-8108	20%	NO VA Placement	
Mild OSA	Cat II		
Closed Head Injury…			
Postconcussion Syndrome			
…Discectomy & Fusion C5-6	Cat III	Cervical Strain	5237	20%	20080516	
Lumbosacral DDD		Lumbar Sprain	5237	20%		
Migraines		Migraine Headaches	8100	50%		
Recurrent Syncope…		Seizure Disorder	8999-8911	0%		
GERD		GERD	7346	10%		
Numbness All Limbs		NO VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Daytime Hypersomnolence.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) neurology narrative summary (NARSUM), the CI’s syncopal condition began in May 2006 after a motor vehicle accident (MVA) in July 2005.  The CI sustained lung injuries but no intracranial trauma; however, he was given the diagnosis of traumatic brain injury (TBI).  He was transported to the emergency room (ER) via ambulance and was noted to have had loss of consciousness, but was conscious and alert during the ER evaluation.  The CI was admitted to the hospital for 1 week due to his injuries.  His CT head scan was normal, as well as the brain MRI.  The CI received treatment at the TBI clinic in August 2005 and his TBI condition was considered resolved.  Shortly after discharge, the CI began to report lower back pain radiating into his legs and was found to have a disk problems.  He underwent discectomy and fusion surgery in October 2005.  Beginning in May 2006, the CI began to have spells in which his legs would abruptly “give out.”  He also developed syncopal events that occurred as often as a few times a week to 1-2 times a month in May 2005.  He had a negative encephalogram (EEG) exam.  The syncopal spells resolved in August or September 2006 and he was cleared to drive a vehicle.  The CI also developed chronic headaches shortly after the MVA which continued despite multiple medication trials.  Due to persistent daytime somnolence, he underwent sleep studies in 2006, and was diagnosed with mild apnea and post-traumatic hypersomnia.  His sleep apnea was treated with CPAP and he received stimulant medication to treat daytime hypersomnolence.  The condition improved with medication.  The MEB forwarded “head injury;” “postconcussion syndrome;” “classical migraine…;” “degeneration of lumbar or lumbosacral intervertebral disc;” “degeneration of cervical intervertebral disc;” “arthropathy associated with neurological disorders;” “hypersomnia…;” “obstructive sleep apnea…;” “deviated nasal septum;” “syncope and collapse” and “perforation of tympanic membrane” for PEB adjudication.  

At the MEB neurology NARSUM examination on 26 April 2007, 5 months prior to separation, the CI reported that he had just begun working when the accident occurred, but had not been able to work since then due to his multiple difficulties.  He noted that he had not been able to find employment and was living with his parents.  The neurological examination was unremarkable with the exception of “patchy decreased” sensation to light touch in all limbs.  The conditions of # 1-closed head injury secondary to MVA; post-concussion syndrome secondary to #1; chronic, recurrent migraines secondary to #1; daytime hypersomnolence, mild obstructive sleep apnea, and recurrent syncope, resolved, were recorded.  On 7 September 2007, 5 months after separation, the CI was seen by civilian neurologist and reported that he could not work because he was unable to drive.  He stated that he fell asleep in the passenger seat, and the CPAP had not improved his mild OSA.  He noted that he slept well at night but that the medication for daytime somnolence made his nauseous.  The neurologist stated, “In summary, I cannot explain his continued constellation of symptoms.”  

At the 30 October 2007 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the examiner noted the records from the treating pulmonologist indicated the CI was “doing okay” in regards to the OSA.  The CI noted that he wanted to return to college, and indicated he was restricted from driving or working.  At the pain medicine consult for the C&P examination dated 20 December 2007, the CI reported he had constant headaches and times where he “blacked out.”  He reported that his medication had not been helpful, and he was unable to work or drive.  The CI also underwent GI consult for the C&P where he reported that he was not using a CPAP machine and denied daytime hypersomnolence.  The neurological assessment for the general C&P examination on 19 March 2008, noted that the CI indicated he was working and had been cleared for daytime driving.  He noted that his headaches kept him away from his work at times.  

The Board directed attention to its rating recommendation based on the above evidence for TDRL placement.  The PEB assigned a 20% rating with the application of analogous coding scheme of 8045-8199-8108 (narcolepsy due to brain trauma).  The VA did not rate the conditions of hypersomnolence, closed head injury, post-concussion syndrome, or OSA.  While the CI had syncopal events, the NARSUM noted these had resolved, and the CI made no mention of them during his neurology visit 2 days before separation.  The VA examiner did not diagnose a condition related to daytime hypersomnolence, nor was OSA assessed.  It was noted that the CI did not have a seizure disorder.  Board members agreed there was no path to a higher rating under any of the seizure disorder codes.  The 8108 code for narcolepsy is referenced to petit mal seizures code (8911) for which the higher rating of 40% requires evidence of at least 5-8 events (minor seizures) weekly.  The last reported episode was documented in an evaluation dated 15 January 2008, 4 months after separation.  The CI reported his spells returned in September 2007 (same month as separation) and that the spells peaked in November 2007 at 3-4 spells a week.  Currently he had 1-2 a week.  Board members agreed, the higher rating of 40% was not justified.  

The Board next considered the Category II conditions.  The treating sleep specialist noted that the OSA condition was mild and that the effects of the condition was not clear since he also had post-traumatic hypersomnia..  The general C&P examination noted that the CI was not using CPAP and had no sleep complaints.  There was no clear evidence that in the absence of the daytime hypersomnolence that the mild OSA would have been symptomatic enough to prescribe CPAP.  The Board found insufficient evidence that the OSA condition was separately unfitting; however, as noted by the treating physician, the condition did contribute to the daytime hypersomnolence condition.  The Board adjudged that the mild OSA, closed head injury secondary to MVA, and the post-concussion syndrome conditions were integral components of the daytime hypersomnolence pathology secondary to the MVA and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the hypersomnolence condition.  

Contended PEB Conditions.  Status post anterior discectomy and fusion C5-6, lumbosacral degenerative disc disease, chronic recurrent migraines, recurrent syncope, GERD, and numbness of the limbs conditions.  

Status post anterior discectomy and fusion C5-6.
Treatment records noted that the CI underwent cervical fusion surgery in 2005 without complications, and post-surgery treatment for this condition was silent going forward.  The NARSUM recorded the CI’s report that his neck pain had not improved since surgery; however, the neurosurgeon indicated the condition post-surgery had improved (2 months after surgery).  

Lumbosacral degenerative disc disease.
The CI reported low back pain secondary to the MVA.  The NARSUM recorded a normal gait and normal motor strength in the lower extremities.  The VA C&P examination, 8 months after separation, documented a ROM of forward flexion to 80 degrees (non-compensable) and no spasm.  There was no evidence of incapacitating episodes.  

Chronic recurrent migraines. 
The service treatment record noted the CI reported to the neurologist in December 2006 that he had not suffered any headaches in the previous 6 months.  Treatment records for this condition fell silent going forward until the NARSUM exam.  At the NARSUM, the CI noted that he had bad headaches 1-2 times a week which caused him to curtail his activities.  The non-medical assessment noted that the CI was not working at all; however, was not specific regarding medical issues except to note that the CI spent 1 hour a week for medical appointments.  

Recurrent syncope. 
The NARSUM recorded the condition of recurrent syncope had resolved.  

Numbness of the limbs. 
The CI reported numbness in all of his limbs.  The NARSUM recorded “patchy” decreased sensation to light touch in all limbs, but noted the CI was able to discern which limb or digit touched lightly when given commands, etc., all other aspects of the neurological examination were normal.  

The CI was not active duty, and therefore, the non-medical assessment offered no insight into the CI’s duty performance.  There was no indication from the record that any of the contended conditions were profiled or were separately judged to fail retention standards.  There was not a preponderance of evidence to support that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the daytime hypersomnolence condition and IAW VASRD §4.124a, the Board recommends no change in the PEB adjudication.  In the matter of the contended status post anterior discectomy and fusion C5-6, lumbosacral degenerative disc disease, chronic recurrent migraines, recurrent syncope, GERD, and numbness of the limbs conditions, the Board recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131107, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 11 Aug 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN